What Is Pancreatic Cancer?

Pancreatic cancer is a disease in which malignant (cancer) cells form in the
tissues of the pancreas.

The
pancreas is a
gland about 6 inches long that is shaped like a thin pear lying on its side.
The wider end of the pancreas is called the head, the middle section is called
the body, and the narrow end is called the tail. The pancreas lies between the
stomach and the
spine.

The pancreas has two main jobs in the body:

To make
juices that help
digest (break down) food.

To make
hormones, such as
insulin and
glucagon, that help control
blood sugar levels. Both of these hormones help the body use and store the
energy it gets from food.

The digestive juices are made by exocrine pancreas cells and the hormones are made by endocrine pancreas cells. About 95% of pancreatic cancers begin in exocrine cells.

What Are Risk Factors for Pancreatic Cancer?

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer;
not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk.

How Is Pancreatic Cancer Diagnosed?

Pancreatic cancer is difficult to detect and
diagnose for the following reasons:

There aren't any noticeable signs or symptoms in the early
stages of pancreatic cancer.

The signs and symptoms of pancreatic cancer, when present, are like
the signs and symptoms of many other illnesses.

The pancreas is hidden behind other
organs such as the stomach,
small intestine,
liver,
gallbladder,
spleen, and
bile ducts.

Tests that examine the pancreas are used to detect (find), diagnose, and
stage pancreatic cancer.

Pancreatic cancer is usually diagnosed with tests and procedures that make
pictures of the pancreas and the area around it. The process used to find out if
cancer
cells have spread within and around the pancreas is called
staging. Tests and procedures to detect, diagnose, and stage pancreatic
cancer are usually done at the same time. In order to plan treatment, it is
important to know the stage of the disease and whether or not the pancreatic
cancer can be removed by
surgery.

The following tests and procedures may be used:

Physical exam and
history: An exam of the body to check general signs of health, including
checking for signs of disease, such as lumps or anything else that seems
unusual. A history of the patient's health habits and past illnesses and
treatments will also be taken.

Blood chemistry studies: A procedure in which a blood sample is checked to
measure the amounts of certain substances, such as
bilirubin, released into the blood by organs and
tissues in the body. An unusual (higher or lower than normal) amount of a
substance can be a sign of disease.

Tumor marker test : A procedure in which a sample of blood,
urine, or tissue is checked to measure the amounts of certain substances,
such as
CA 19-9, and
carcinoembryonic antigen (CEA), made by organs, tissues, or
tumor cells in the body. Certain substances are linked to specific types of
cancer when found in increased levels in the body. These are called
tumor markers.

MRI (magnetic resonance imaging): A procedure that uses a magnet,
radio waves, and a computer to make a series of detailed pictures of areas
inside the body. This procedure is also called nuclear magnetic resonance
imaging (NMRI).

CT scan (CAT scan): A procedure that makes a series of detailed pictures of
areas inside the body, taken from different angles. The pictures are made by a
computer linked to an
X-ray machine. A dye may be
injected into a
vein or swallowed to help the organs or tissues show up more clearly. This
procedure is also called computed tomography, computerized tomography, or
computerized axial tomography. A
spiral or
helical CT
scan makes a series of very detailed pictures of areas inside the body using
an X-ray machine that scans the body in a spiral path.

PET scan (positron emission tomography scan): A procedure to find
malignant
tumor cells in the body. A small amount of
radioactive
glucose (sugar) is injected into a vein. The PET scanner rotates around the
body and makes a picture of where glucose is being used in the body. Malignant
tumor cells show up brighter in the picture because they are more active and
take up more glucose than normal cells do. A PET scan and CT scan may be done at
the same time. This is called a
PET-CT.

Abdominal
ultrasound : An ultrasound exam used to make pictures of the inside of the
abdomen. The
ultrasound transducer is pressed against the skin of the abdomen and directs
high-energy sound waves (ultrasound) into the abdomen. The sound waves bounce
off the internal tissues and organs and make echoes. The transducer receives the
echoes and sends them to a computer, which uses the echoes to make pictures
called
sonograms. The picture can be printed to be looked at later.

Endoscopic ultrasound (EUS): A procedure in which an
endoscope is inserted into the body, usually through the mouth or
rectum. An endoscope is a thin, tube-like instrument with a light and a
lens for viewing. A probe at the end of the endoscope is used to bounce
high-energy sound waves (ultrasound) off internal tissues or organs and make
echoes. The echoes form a picture of body tissues called a sonogram. This
procedure is also called endosonography.

Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to
X-ray the
ducts (tubes) that carry
bile from the liver to the gallbladder and from the gallbladder to the small
intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or
slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is
passed through the mouth,
esophagus, and stomach into the first part of the small intestine. A
catheter (a smaller tube) is then inserted through the endoscope into the
pancreatic ducts. A
dye is injected through the catheter into the ducts and an X-ray is taken.
If the ducts are blocked by a tumor, a fine tube may be inserted into the duct
to unblock it. This tube (or
stent) may be left in place to keep the duct open. Tissue samples may also
be taken.

Percutaneous transhepatic cholangiography (PTC): A procedure used to
X-ray
the liver and bile ducts. A thin needle is inserted through the skin below the
ribs and into the liver. Dye is injected into the liver or bile ducts and an
X-ray is taken. If a blockage is found, a thin, flexible tube called a stent is
sometimes left in the liver to
drain bile into the small intestine or a collection bag outside the body.
This test is done only if
ERCP cannot be done.

Laparoscopy : A
surgical procedure to look at the organs inside the abdomen to check for
signs of disease. Small
incisions (cuts) are made in the wall of the abdomen and a
laparoscope (a thin, lighted tube) is inserted into one of the incisions.
The laparoscope may have an ultrasound probe at the end in order to bounce
high-energy sound waves off internal organs, such as the pancreas. This is
called laparoscopic ultrasound. Other instruments may be inserted through the
same or other incisions to perform procedures such as taking tissue samples from
the pancreas or a sample of
fluid from the abdomen to check for cancer.

Biopsy: The removal of cells or tissues so they can be viewed under a
microscope by a
pathologist to check
for signs of cancer. There are several ways to do a biopsy for pancreatic
cancer. A fine needle or a core
needle may be inserted into the pancreas during an X-ray or ultrasound to remove
cells. Tissue may also be removed during a laparoscopy.

What Is the Prognosis for Pancreatic Cancer?

The prognosis (chance of recovery) and treatment options depend on the following:

Whether or not the tumor can be removed by surgery.

The stage of the cancer (the size of the tumor and whether the cancer
has spread outside the pancreas to nearby tissues or
lymph nodes or to other places in the body).

The patient's general health.

Whether the cancer has just been diagnosed or has
recurred (come back).

Pancreatic cancer can be controlled only if it is found before it has spread,
when it can be completely removed by surgery. If the cancer has spread,
palliative treatment can improve the patient's
quality of life by controlling the symptoms and
complications of this disease.

Stages of Pancreatic Cancer

Tests and procedures to stage pancreatic cancer are usually done at
the same time as diagnosis.

Tests and procedures to stage pancreatic cancer are usually done at the same
time as diagnosis.

The process used to find out if
cancer has spread within the
pancreas or to other parts of the body is called
staging. The information gathered from the staging process determines the
stage of the disease. It is important to know the stage of the disease in
order to plan treatment. The results of some of the tests used to
diagnose pancreatic cancer are often also used to stage the disease. See the General
Information section for more information.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas.

Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.

Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called
metastasis. Cancer
cells break away from where they began (the
primary tumor) and travel through the lymph system or blood.

Lymph system. The cancer gets into the lymph system, travels through
the lymph vessels, and forms a
tumor (metastatic tumor) in another part of the body.

Blood. The cancer gets into the blood, travels through the blood
vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For
example, if pancreatic cancer spreads to the
liver, the cancer cells in the liver are actually pancreatic cancer cells.
The disease is metastatic pancreatic cancer, not liver cancer.

The following stages are used for pancreatic cancer:

Stage 0 (Carcinoma in Situ)

In stage 0,
abnormal
cells are found in the lining of the
pancreas. These abnormal cells may become
cancer and spread into nearby normal
tissue. Stage 0 is also called
carcinoma in situ.

Stage I

In
stage I,
cancer has formed and is found in the
pancreas only. Stage I is divided into stage IA and stage IB, based on the
size of the
tumor.

Stage IA: The
tumor is 2
centimeters or smaller.

Stage IB: The
tumor is larger than 2
centimeters.

Stage II

In
stage II,
cancer may have spread to nearby
tissue and
organs, and may have spread to
lymph nodes near the
pancreas. Stage II is divided into stage IIA and stage IIB, based on where
the cancer has spread.

Stage IIA: Cancer has spread to nearby
tissue and
organs but has not spread to nearby
lymph nodes.

Stage IIB: Cancer has spread to nearby
lymph nodes and may have spread to nearby
tissue and
organs.

Stage III

In
stage III,
cancer has spread to the major
blood vessels near the
pancreas and may have spread to nearby
lymph nodes.

Stage IV

In stage IV, cancer may be of any size and has spread to distant organs, such as
the liver, lung, and peritoneal
cavity. It may have also spread to organs and
tissues
near the
pancreas
or to
lymph nodes.

What Are the Standard Treatments for Pancreatic Cancer?

There are different types of treatment for patients with pancreatic cancer.

Different types of treatment are available for patients with
pancreatic cancer. Some treatments are
standard (the currently used treatment), and some are being tested in clinical trials. A
treatment clinical trial is a research
study meant to help improve current treatments or obtain information on new
treatments for patients with cancer. When clinical trials show that a new treatment is better than the
standard treatment, the new treatment may become the standard treatment.
Patients may want to think about taking part in a clinical trial. Some clinical
trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

One of the following types of surgery may be used to take out the tumor:

Whipple procedure: A surgical procedure in which the head of the
pancreas, the gallbladder, part of the
stomach, part of the small intestine, and the
bile duct are removed. Enough of the pancreas is left to produce
digestive juices and insulin.

Total pancreatectomy: This operation removes the whole pancreas, part of the
stomach, part of the small intestine, the
common bile duct, the gallbladder, the
spleen, and nearby
lymph nodes.

Distal pancreatectomy: The body and the tail of the pancreas and usually the
spleen are removed.

If the cancer has spread and cannot be removed, the following types of
palliative surgery may be done to relieve
symptoms and improve
quality of life:

Surgical
biliary bypass: If cancer is blocking the small intestine and
bile is building up in the gallbladder, a biliary bypass may be done. During
this operation, the doctor will cut the gallbladder or bile duct and sew it to
the small intestine to create a new pathway around the blocked area.

Endoscopic
stent placement: If the tumor is blocking the bile duct, surgery may be done
to put in a stent (a thin tube) to
drain bile that has built up in the area. The doctor may place the stent
through a
catheter that drains to the outside of the body or the stent may go around
the blocked area and drain the bile into the small intestine.

Gastric bypass: If the tumor is blocking the flow of food from the stomach,
the stomach may be sewn directly to the small intestine so the patient can
continue to eat normally.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy
X-rays or other types of
radiation to kill cancer
cells or keep them from growing. There are two types of radiation therapy:

Internal radiation therapy uses a
radioactive substance sealed in needles,
seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type and
stage of the cancer being treated. External radiation therapy is used to
treat pancreatic cancer.

Chemotherapy

Chemotherapy is a cancer treatment that uses
drugs to stop the growth of cancer cells, either by killing the cells or by
stopping them from dividing. When chemotherapy is taken by mouth or
injected into a
vein or muscle, the drugs enter the bloodstream and can reach cancer cells
throughout the body
(systemic chemotherapy). When chemotherapy is placed directly into the
cerebrospinal fluid, an
organ, or a body
cavity such as the
abdomen, the drugs mainly affect cancer cells in those areas
(regional chemotherapy).
Combination chemotherapy is treatment using more than one anticancer drug.
The way the chemotherapy is given depends on the type and stage of the cancer
being treated.

Chemoradiation therapy

Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances
to identify and attack specific cancer cells without harming normal cells.
Tyrosine kinase inhibitors (TKIs) are targeted therapy drugs that block
signals needed for tumors to grow.
Erlotinib is a type of TKI used to treat pancreatic cancer.

There are treatments for pain caused by pancreatic cancer.

Pain can occur when the tumor presses on
nerves or other organs near the pancreas. When pain
medicine is not enough, there are treatments that act on nerves in the abdomen
to relieve the pain. The doctor may inject medicine into the area around
affected nerves or may cut the nerves to block the feeling of pain. Radiation
therapy with or without chemotherapy can also help relieve pain by shrinking the
tumor.

Patients with pancreatic cancer have special nutritional needs.

Surgery to remove the pancreas may affect its ability to make pancreatic
enzymes that help to digest food. As a result, patients may have problems
digesting food and absorbing nutrients into the body. To prevent malnutrition,
the doctor may prescribe medicines that replace these enzymes.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical
trials. It may not mention every new treatment being studied. Information about
clinical trials is available from the
NCI website.

Biologic therapy

Biologic therapy is a treatment that uses the patient's
immune system to fight cancer. Substances made by the body or made in a
laboratory are used to boost, direct, or restore the body's natural defenses
against cancer. This type of cancer treatment is also called biotherapy or
immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a
clinical trial may be the best treatment choice. Clinical trials are part of
the cancer research process. Clinical trials are done to find out if new cancer
treatments are safe and effective or better than the
standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical
trials. Patients who take part in a clinical trial may receive the standard
treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer
will be treated in the future. Even when clinical trials do not lead to
effective new treatments, they often answer important questions and help move
research forward.

Patients can enter clinical trials before, during, or after starting their
cancer treatment.

Some clinical trials only include patients who have not yet received
treatment. Other trials test treatments for patients whose cancer has not gotten
better. There are also clinical trials that test new ways to stop cancer from
recurring (coming back) or reduce the
side effects of cancer treatment.

Follow-up tests may be needed

Some of the tests that were done to
diagnose the cancer or to find out the
stage of the cancer may be repeated. Some tests will be repeated in order to
see how well the treatment is working. Decisions about whether to continue,
change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment
has ended. The results of these tests can show if your
condition has changed or if the cancer has
recurred (come back). These tests are sometimes called
follow-up tests or check-ups.

Treatment Options by Stage

Stages I and II Pancreatic Cancer

Treatment of stage I and stage II pancreatic cancer may include the
following:

Surgery.

Surgery followed by chemotherapy.

Surgery followed by chemoradiation.

A clinical trial of combination chemotherapy.

A clinical trial of chemotherapy and targeted therapy, with or without
chemoradiation.

A clinical trial of chemotherapy and/or radiation therapy before
surgery.

Stage III Pancreatic Cancer

Treatment of stage III pancreatic cancer may include the following:

Palliative surgery or stent placement to bypass blocked areas in ducts
or the small intestine.

Chemotherapy followed by chemoradiation.

Chemoradiation followed by chemotherapy.

Chemotherapy with or without targeted therapy.

A clinical trial of new anticancer therapies together with chemotherapy
or chemoradiation.

A clinical trial of radiation therapy given during surgery or internal
radiation therapy.

Stage IV Pancreatic Cancer

Treatment of stage IV pancreatic cancer may include the following:

Palliative treatments to relieve pain, such as nerve blocks, and other
supportive care.

Palliative surgery or stent placement to bypass blocked areas in ducts
or the small intestine.

Chemotherapy with or without targeted therapy.

Clinical trials of new anticancer agents with or without chemotherapy.

Treatment Options for Recurrent Pancreatic Cancer

Recurrent pancreatic cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the pancreas or in other parts of the body. Treatment of recurrent pancreatic cancer may include the following:

Palliative surgery or stent placement to bypass blocked areas in ducts
or the small intestine.

Palliative radiation therapy to shrink the tumor.

Other palliative medical care to reduce symptoms, such as nerve blocks
to relieve pain.

Chemotherapy.

Clinical trials of chemotherapy, new anticancer therapies, or biologic
therapy.

Pancreatic Cancer Symptoms and Signs

The initial signs and symptoms of pancreatic cancer are often nonspecific and have a gradual or slow onset. The main symptoms of pancreatic cancer include the following:

Pain in the abdomen, the back, or both; often the pain becomes constant